Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins, Baltimore, MD 


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free, Adelaide, Australia

"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA



Catheter Ablation

Now A-Fib Free: A 23-Year Atrial Fibrillation Ordeal, Trial, Tribulations and Recovery

By Charn Deol, Richmond, British Columbia, Canada, May 2017
Personal A-Fib story by Charn Deol, BC, Canada at A-Fib.com

Charn Deol, B.C., Canada

My medical issues with atrial fibrillation started when I was 43 in August of 1993 when I was aware of having a few skipped heartbeats. I had just returned to Canada having been working extensively for the last few years in Southeast Asia. About a week later, the irregular heart beating got worse in duration.

At the same time, a dull aching pain started in the left chest region the size of a 50-cent piece.

A-Fib Drugs Don’t Work, Chest Pain Condition Worse

Upon being sent to a heart specialist in September 1993, numerous drugs were prescribed to keep my heart in rhythm (digoxin, flecainide, sotalol). They did not work, some had serious side effects, and every few days I would go into atrial fibrillation.

The atrial fibrillation happened once or twice per week and lasted from a few hours to 24 hours. Then it would stop on its own, and the heart would go into normal sinus rhythm.

Second medical condition: At the same time, the very centered pain in the upper left chest area kept getting worse and added to the debilitation of daily life. These medical conditions started my long journey to find relief (cure) from two medical conditions that were not being controlled or cured by conventional medical treatments.

Alternative Healthcare Practitioners―India & China, Too

In my search for a cure(s), I met a family practitioner and other medical and alternative specialists who used treatment protocols that could be labeled ‘experimental’ or ‘out of the box’, as they say.

I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

While discovering alternative medical treatments in 1994, I also went to India for Ayurvedic treatment [one of the world’s oldest holistic healing systems] and even to China for treatment. Most alternative (non-allopathic) medical practitioners look at the body as an interconnected processing unit and believed in my case that the pain in the left chest and the atrial fibrillation were connected. This was not the thinking of the allopathic doctors, so I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

Having been to a multitude of healthcare practitioners, numerous chiropractors, massage therapists and other more esoteric healthcare practitioners (100s over the 23 years), there was no resolution to my medical condition.

Encainide Drug Therapy: Up and Out

The heart specialist that gave me sotalol [an antiarrhythmic drug] in 1995 gave me a dose that dropped the heartbeat to 30 beats per minute putting me into the emergency room, but the drug had no effect on my atrial fibrillation.

In 1996 seeing my third cardiologist, I was put on a drug called encainide [also an antiarrhythmic drug], to be used on an as needed basis [pill-in-the-pocket].  It worked and would stop my atrial fibrillation in approximately 20 minutes.

But it had no effect on the chest pain which was getting worse now with a pain spot in the left shoulder blade area also the size of a 50-cent piece having started out of nowhere.

Encainide is a class Ic antiarrhythmic agent. It is no longer used because of its frequent proarrhythmic side effects.

About 6 months after starting on the encainide, one of my friend’s son with a heart condition since childhood passed away. And I was told he had just been started on a new drug for him called “encainide” along with “sotalol”. The same cardiologist had been providing this drug free of charge to me, so I was pleased that it worked for me and cost me nothing.

The problem I found out was that it was illegal for the cardiologist to prescribe this drug because it had killed too many people. When he got caught, then encainide was no longer available. (Encainide is a class 1C antiarrhythmic drug no longer used because of its frequent proarrhythmic effects.)

Chelation for Very High Levels of Mercury

I had the highest level of mercury ever seen by the lab in any of their patients.

While all the above was going on, I was tested for heavy metals through urine analysis. It was discovered that I had the highest level of mercury ever seen by the lab in any of their patients (7400 nmol/dl). So I started protocols to take the mercury out of my body using chelation treatments with EDTA and then DMPS and DMSA (metal chelators).

At the same time, my other medical practitioners had me on oral and IV multivitamins and mineral protocols.

Mercury Cleared, Atrial Fibrillation Stops!

By 2000, the mercury was finally out of my system and my atrial fibrillation stopped! It is known mercury can concentrate in nerve tissue. While only a correlative relationship―mercury out of system―my atrial fibrillation did stop.

Chest Pain Condition Worse than Ever

From 2000 to 2010 I had NO atrial fibrillation. But the chest pain condition did not stop, and it got worse.

From 2000 to 2010 I had no atrial fibrillation. But the chest pain condition did not stop, and it got worse extending into my gut region. All medical protocols tried could not alleviate this pain, nor was any etiology discovered as to what was the underlying cause of the pain condition.

Thanks to my resiliency, I was still able to go hiking, skiing, travel and work part-time on my own schedule. But it took great perseverance.

After 10 Years A-Fib Returns―and Heavy Levels of Lead (This Time)!

In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week.

I was immediately tested for heavy metals again, and this time I had high levels of lead, not mercury. Even with thorough investigations of potential sources for this lead contamination in my body, no source was discovered. We worked (and continue to work) on getting these lead levels down (I had no high lead levels back in the 1990’s when tested―only mercury).

Amiodarone Bad Side Effects

I again began doing alternative treatments to deal with the atrial fibrillation and the pain condition, nothing worked. I went to China again for treatments, IV EDTA infusions again, etc., but the pain persisted at high levels and the atrial fibrillation kept getting worse.

A new cardiologist put me on a new drug called amiodarone. This drug lead to paranoia. This is another cardiologist I dropped.

In 2012, I saw a new cardiologist who put me on flecainide again. And when it did not work, he provided me with a new drug called amiodarone. This drug lead to paranoia and left me with an epididymitis in my right testicle which I suffer from to this day. (Epididymitis is inflammation of the tube at the back of the testicle that stores and carries sperm.) He had no compassion for my dilemma. This is another cardiologist I dropped.

Ablation in Vancouver, B.C. Fails―A-Fib Worse and More Chest Pain

By late 2014, the atrial fibrillation was occurring on average every second day and lasting 24-38 hours.  My next cardiologist sent me to the Atrial Fibrillation clinic in Vancouver where I was evaluated by an electrophysiologist. The A-Fib was very debilitating, so I was ready for surgery.

VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected

WATCH A VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected (4:15)

I asked for the most experienced electrophysiologist at the clinic to do the surgery. I waited an extra 3 months for the surgery because this highly qualified electrophysiologist was in so much demand.

Finally, in November 2015 I had the ablation therapy (it took approximately 2.5 hours). I came out of the surgery worse than ever. The atrial fibrillation did not stop, and the pain was worse than ever in my left chest, left shoulder-blade and gut regions.

AV Node Ablation & Pacemaker?―No! No! No!

The electrophysiologist wanted to wait for the 6 month recuperation period after the ablation therapy to see if I would go into regular sinus rhythm. By September 2016 (9 months later), I was worse than ever. In November, I saw my electrophysiologist under the impression that he would do another ablation treatment, since I was told and with my own research had confirmed that ablation treatments may be required for up to four times for the treatment to work.

This “top” electrophysiologist recommended I have a pacemaker put in and the AV node be ablated instead, so that the pacemaker could take over the regular beating of the heart. I asked the electrophysiologist why not do further ablation treatments as per the standard practice. He said if that is what I wanted, he would do another ablation. This was quite disconcerting―I am relying on his extensive knowledge to help me in a field where I am no expert. We agreed to set up a surgical date for a second ablation on December 12, 2016.

My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital.

Upon leaving the office and arriving home, I informed my wife of the unpleasant appointment I had with the electrophysiologist, especially his lackadaisical attitude towards my serious heart condition. As a patient, the relationship is somewhat like that of a child with a parent. The patient is naïve, scared, distraught and looking for a path of reassurance from the medical profession. This was not the case in this situation.

This is when “gut instincts” come into play. My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital and search for an alternative path. (And I canceled my December 12, 2016 scheduled ablation.)

Counseling with Steve Ryan

Having been a reader of Steve Ryan’s website, I reached out to him and agreed for him to become my advocate and provide me with advice on how to deal with my current concerns over either going along with having a pacemaker placed in my chest along with ablation of the AV node OR to try a second ablation. Steve recommended a second ablation and the Bordeaux Clinic―it was too early to place a pacemaker/ablate the AV node at this stage.

Following this detailed discussion with Steve, I spoke with my wife and got a hold of the Bordeaux Clinic in France on December 2, 2016. With some back and forth email communication, ablation therapy was arranged for December 12, 2016. Somehow with luck and quick action, my wife and I were on an airplane to France and arrived in Bordeaux on December 10.

Second Ablation in Bordeaux and Use of CardioInsight Vest

The surgery on December 12 was done by Prof. Mélèze Hocini. Instead of taking the standard time of 2.5 to 3 hours for the surgery, it took well over 6 hours until approximately 4 pm. Dr Hocini was on her feet and exhausted.

My surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter.

I was informed the next day that my surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter. It appeared the “top” specialist I had used in Vancouver had not done his job properly. (Remember that I had been worse for the year after my first ablation).

Dr. Hocini was able to see the numerous sites leading to the atrial fibrillation/flutter in my heart due to an advanced computer assisted mapping vest (CardioInsight) which helps the electrophysiologist see in more detail cells in the heart that are acting erratically.  This system is just starting to be used in the U.S. by a few doctors. (See Bordeaux ECGI CardioInsight)

Successful Ablation—No A-Fib, But Chest Pain Condition Continues

I felt great the day after the surgery, no atrial fibrillation or flutter. Pain syndrome still there. I remained in the hospital for 4 more days and all went well, and then stayed in France for 7 more days sightseeing. No problems. I was to continue on Xarelto to keep the blood thin [for risk of stroke].

At Home A-Fib Returns with Persistent A-Flutter

Upon arriving back in Canada, the atrial fibrillation and flutter returned. Dr Hocini recommended cardioversion which I did twice but I still ended up in persistent atrial flutter with a heartbeat in the 130 range but no longer irregular.

Another cardioversion with sotalol converted my heart beat to sinus rhythm. I have now remained in rhythm since February 17, 2017.

Beta Blockers were tried to lower the heartbeat for a few weeks which did not work. Dr. Hocini recommended another cardioversion with sotalol prescribed for after the cardioversion. This was done on February 17, 2017. The heartbeat converted to sinus rhythm (65 heartbeat and was regular).

Normal Sinus Rhythm―4+ Months So Far

I have now remained in rhythm since February 17, 2017 with a quick flutter occurring once in a while. Since I am sensitive to prescription medications, I was placed on a low dose of 40 mg sotalol 2 times per day.

Minerals, Vitamin IVs for Inflammation of the Heart

With my other medical practitioners, I also had mineral and vitamin IVs during this time to help alleviate the inflammation in my heart from the surgery. I also took (and continue to take) vitamins and supplements as recommended by the other medical professionals treating me to keep the inflammation in the heart down.

Dr. Hocini had stated that since my ablation surgery was so complicated, I might have to go back to Bordeaux for another ablation. I have to get through the recommended 6 month recuperation time frame to see if the surgery has been successful. The last 3 months have me heading in the right direction of recovery.

Lessons Learned: After 23 Years with A-Fib

From this experience I’ve learned to obtain as much knowledge as possible of your condition. Trust your gut feelings if you feel uncomfortable with your surgeon. Increase your intake of nutritious foods and supplements prior to and after the surgery. Steve Ryan’s website provided me with the knowledge to make educated decisions.

If you have the funds and/or a complicated atrial fibrillation situation, please find the best surgeon you can and then still question him/her. Get a second [or third] opinion if your gut tells you to.

Doctors are just human beings with positive and negative traits like the rest of us. My first surgeon did not do his job properly in my first ablation and was flippant in his attitude in recommending a second surgical treatment.

With luck, trusting my gut instinct, educating myself, and a great family support system, I was able to find the best clinic in the world to treat me for this very debilitating medical condition.

I welcome your email if I can be of help to you.

Charn Deol, May 2017
charnee@gmail.com

P.S. FYI: My chest pain problem persists and goes undiagnosed, but that’s a story for another website!

Editor’s Comments:
Three month ‘blanking’ period: Charn’s A-Fib returned after his successful second ablation. This is quite common in more difficult cases. Your heart is ‘learning’ to beat normally again. That’s why doctors wait for at least three months before declaring your ablation a success. In Charn’s case, during the first two months, a couple rounds of cardioversions were followed by a third with sotalol prescribed after the cardioversion. This worked to get his heart back into and stay in normal sinus rhythm (NSR).
Be a proactive patient: Charn’s story is truly inspiring and an example of being proactive and not giving up. Do research yourself, get advice, and check out alternatives! We’ve been conditioned to trust doctors. Sometimes we just have to say “NO! That doesn’t make sense to me”. It’s okay to fire your doctor!
I told Charn an AV Node ablation is a treatment of last resort; it destroys the AV Node, the heart’s natural pacemaker. There’s no going back and you are forever pacemaker dependent.
Instead, I advised Charn to seek a second ablation and supplied him a list of Master EPs who routinely treat difficult, complex cases. Kudos to him for deciding to go to the Bordeaux group, considered the best in the world. [For more about Bordeaux, see my article, ‘2016 Cost of Ablation by Bordeaux Group (It’s Less Than You Might Think)’].
Chelation therapy: Chelation is FDA approved for lead removal and is the preferred medical treatment for metal poisoning. But few doctors perform chelation therapy or provide heavy metal testing. To find a doctor for these therapies, go to: http://www.acam.org. (They also do IV therapy for vitamin C and other vitamins and minerals which seems to have helped Charn.)
Amiodarone drug therapy: Amiodarone is considered the most effective of the antiarrhythmic drugs, but it’s also the most toxic and is notorious for bad side effects, including death. It’s generally prescribed only for short periods of time such as for a few months after a catheter ablation and under very close supervision. (For more about Amiodarone, see my article, ‘Amiodarone: Most Effective and Most Toxic‘.

Read our 12-page free report.

Charn’s second ablation Operating Report: Charn’s ablation was more difficult than most. He had been in A-Fib off and on for 23 years. In addition to having to work around a previous failed ablation, Dr. Hocini had to track down and ablate many non-PV triggers. Using the CardioInsight system, Dr. Hocini found A-Fib sources in the septum and in the anterior Left Atrium (LA) region, and his left and right inferior PVs had to be re-isolated.
But Dr. Hocini didn’t stop there. Using pacing again, Dr. Hocini found peri-mitral flutter in Charn’s left atrium which terminated by completing an anterior mitral line and required high energy because of the thickness of his heart tissue. Dr. Hocini had to work on Charn for six hours to the point of exhaustion.
Charn’s chest pain continues: Charn’s debilitating chest pain seemed to start when he first developed A-Fib. I’m disappointed that being A-Fib-free didn’t get rid of the pain he still experiences. I’ve never heard of pain like this coming from A-Fib. Charn has seen many doctors and tried alternative strategies to no avail.
If anyone has any ideas, strategies, or insights to help Charn’s pain, please email me.

 

FAQ: After Ablation—What’s my Chance of Staying A-Fib Free?

There is a tendency for ablated heart tissue to heal itself, regrow the ablated tissue, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

An A-Fib.com reader sent me this question about recurrence of his A-Fib after a successful ablation:

Illustration of catheter ablation

Illustration of catheter ablation of pulmonary vein

“Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

Regrowth/Reconnection of Ablated Heart Tissue

I think your chances of staying A-Fib free are pretty good.

If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again. When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. But it’s too early in the history of PVA(I)s to say this definitively. …read the rest of my answer.

In Persistent A-Fib? Time Matters: Ablate Sooner for Better Outcomes

Note: This research study is important if you have Persistent A-Fib or your Paroxysmal A-Fib has progressed to Persistent A-Fib.

The Cost of Waiting to Ablate

In patients with persistent atrial fibrillation undergoing ablation, the time interval between the first diagnosis of persistent A-Fib and the catheter ablation procedure had a strong association with the ablation outcomes.

Cleveland Clinic researchers found that shorter diagnosis-to-ablation time spans were associated with better outcomes. Longer diagnosis-to-ablation times was associated with a greater degree of atrial remodeling.

When A-Fib becomes persistent A-Fib, the ‘first diagnosis-to-ablation time span’ had a stronger impact on outcomes than the time spent in paroxysmal A-Fib.

According to electrophysiologist Dr. Oussama Wazni, “once the diagnosis of atrial fibrillation is made, it’s important not to spend too much time trying to keep a patient in normal rhythm with medical [drug] therapy” before referring for radio-frequency ablation.” Dr. Wazni is Co-Director of the Center for Atrial Fibrillation at the Cleveland Clinic.

His comments are based on the published analysis of two-year outcomes among 1,241 consecutive patients undergoing first-time ablation of persistent atrial fibrillation over an eight-year period at Cleveland Clinic. All patients had successful isolation of all 4 PVs (pulmonary veins), and the superior vena cava was isolated in 69.6%. In addition, Left Atrium ablations (including complex fractionated electrograms) were performed in 65.6% of patients.

First Diagnosis-to-Ablation Time Span: The Shorter the Better

Importantly, the first diagnosis-to-ablation time interval (of persistent A-Fib) had a stronger impact on outcomes than the time spent with a paroxysmal A-Fib diagnosis or the duration of continuous A-Fib before the ablation procedure.

These findings suggest that A-Fib is a disease with a continuous spectrum…
The findings suggest that A-Fib is a disease with a continuous spectrum, with patients at the extreme end of that spectrum having higher arrhythmia recurrence rates after catheter ablation, whereas patients with shorter diagnosis-to-ablation times having lower recurrence rates.

The analysis was published in the Jan. 2016 issue of Circulation: Arrhythmia and Electrophysiology. (Read online or download as a PDF.)

Reference for this Article

2017 AF Symposium: Live Case of Ablation with FIRM Mapping System

Dr David Wilber Loyola University

D. Wilber, MD

In a live case, Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. ‘FIRM’ stands for Focal Impulse and Rotor Modulation.

Patient background: The patient was a 54-year-old male in persistent A-Fib for 7 months, obese with a BMI of 31, hypertension, diabetes, and obstructive sleep apnea. He was symptomatic, with fatigue and decreased exercise tolerance. An MRI showed his Left Atrium was 15.5% fibrotic. (If using Dr. Nassir Marrouche’s Utah I–IV Classification System to rate the patient’s amount of fibrosis, this patient would be “Utah Stage 2”, i.e., a reasonable candidate for a catheter ablation.)

Voltage & FIRM Mapping: Rotors Ablated First

FIRM mapping display of left atrial rotor during atrial fibrillation.

FIRM mapping display of left atrial rotor during atrial fibrillation.

In live video streaming from Chicago, Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation (PVI).

He explained that the concept of terminating A-Fib during a PVI ablation doesn’t work with the FIRM system. Instead, he looks to ablate rotational areas (which are usually 2.2 cm across). He does this by using a Contact Force sensing catheter usually at 35 watts for 30 sec.

During this ablation, he found one rotor at the base of the Left Atrial Appendage (LAA). (In the followup panel discussion, Dr. Andrea Natale commented that he and his colleagues now look first for A-Fib signals in the LAA.)

FIRM Rotors Hard to See

VIDEO examples: Dr. Wilber showed a video using FIRM in which [even to my untrained eye] it was easy to see a rotor. But he showed other videos where the overlapping, swirling waves made it difficult to see where exactly a rotor was coming from.

Editor’s Comments:
This patient was at great risk of recurrence after a catheter ablation, because of his various illnesses (comorbidities). By restoring him to normal sinus rhythm, he would be able to exercise and develop life-changing habits to reduce his obesity, diabetes, and hypertension.
ECGI CardioInsight system: Focal and re-entrant driver maps

ECGI CardioInsight system: Focal and re-entrant driver maps

Abbott Topera FIRM vs Medtronic ECGI CardioInsight:  In comparison to the ECGI CardioInsight system where the rotors and focal sources are very obvious (even to untrained observers), the FIRM system display of rotors are often confusing and hard to identify. Dr. Wilber acknowledged that it takes study and experience with the FIRM system to use it effectively.
To me, the Abbott Topera FIRM system seems hard to use. In head-to-head competition with the Medtronic ECGI CardioInsight system, I predict the FIRM system will probably not survive.
The Medtronic ECGI CardioInsight system has been in limited use in Europe and in 2017 has begun a limited rollout in the U.S.

For more on the Medtronic ECGI CardioInsight, see my article: ECGI Mapping Now Available in U.S.

For more about Dr. Nassir Marrouche’s Utah I–IV Classification System, see my article: Fibrosis Risk and the U. of Utah/CARMA website.

Reference for this Article

2017 AF Symposium: Movin’ it—Protecting the Esophagus During Ablation

2017 AF Symposium

Movin’ it: Protecting the Esophagus During Ablation

Live case presenters: Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt from the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, TX. Moderator: Dr. Andrea Natale.

Patient background: A 79-year-old female needed a ‘re-do’ second ablation. She had persistent A-Fib and hypertension. Her first ablation was August 15, 2016 where they couldn’t terminate her Flutter. Because the temperature probe in her esophagus showed a rise in temperature when they tried to ablate certain areas, “we were not as aggressive as we would have liked.”

The Danger: Esophageal Fistula

During an ablation, doctors take great precautions to not heat or injure the esophagus which lies behind the posterior wall of the left atrium. Injuring the esophagus can, in very rare cases, cause an atrial esophageal fistula which can be fatal.

Fear of causing esophageal injury can cause the EP to modify the ablation lesion set delivery, thereby reducing ablation success by:

1. Reducing the wattage or amount of energy delivered to the left atrium wall which causes less complete scarring; and/or

2. Relocating the ablation lesion to a less desirable area

For this patient: During her first ablation: the doctors noticed a rise in temperature of the probe inserted in her esophagus, so her doctors stopped ablating in that area. Consequently, the A-Fib signal source(s) in that area were not isolated effectively. Result: her A-Flutter was not terminated.

Solution: Esophageal Displacement Tool

The esophagus is not a rigid, inflexible pipe but rather like a hose made out of flexible muscle fibers. It can naturally migrate side-to-side 2-3 cm on its own.

For this live streaming ablation, a new esophagus displacement tool was used: the EsoSure Esophageal Retractor. The tool allows doctors to re-position a section of the esophagus away from the nearby heart tissue and avoid the heat generated during ablation.

The inventor of the device, Steven W. Miller, RN and EP nurse, demonstrated his device to me at the AF Symposium Exhibit Hall.

EsoSure Esophageal Retractor: Shape adjusts to body temperature at A-Fib.com

EsoSure Esophageal Retractor: Shape adjusts to body temperature

At room temperature, the stylet is fairly straight which allows it to be easily inserted into a commonly used gastric tube which is routinely placed down the esophagus by the anesthesia staff. But as the stylet warms to body temperature, it takes on a greater curve. He inserted the stylet into warmed water. You could see how the stylet changed shape and developed a greater curve.

Depending on how the stylet is positioned, it can displace the esophagus up to 2-3 cm to the left or right depending on each person’s anatomy.

Using the EsoSure Retractor, the EP can easily and safely move the esophagus away from any area being ablated. It is FDA approved and has been used by different practitioners more than 700 times without damaging the esophagus.

Live Case Using the EsoSure Retractor

In this re-do ablation, the 79-year-old female patient was in A-Fib when the ablation started. They cardioverted her, but she went right back into A-Fib.

Entrainment (pacing) mapping was used to identify non-PV triggers. Since they had to ablate in the posterior of the left atrium next to the esophagus, they simply moved the EsoSure Retractor up and down to displace the esophagus. It seemed very easy to do.

The EPs mentioned that, with the use of this displacement device, they could now ablate at a higher wattage without fear of harming the esophagus. They also ablated the Left Atrial Appendage area to restore her to sinus rhythm.

What Patients Need to Know

Displacing the esophagus is a major medical advance: The EsoSure Esophageal Retractor is a major medical advance that will significantly improve not only the safety but the effectiveness of catheter ablations. Compared to any other gear in the ablation lab, the EsoSure Retractor is inexpensive ($365-$395 depending on quantity ordered). Any EP lab can and should use it, (or something similar).

Esophagus injury: All too often the esophagus lies behind the right pulmonary vein openings. Doctors have to limit both the placement and the power of their lesions out of fear of damaging the esophagus.

But being able to move the esophagus solves this problem. Ablations will be more effective, and the danger of producing an Atrial Esophageal Fistula (while rare) will be greatly reduced, if not eliminated. It will also reduce ablation procedure time.

Ask your EP: If you are scheduling an ablation, ask your doctors about their plan to prevent esophageal injury.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Saturday, March 11, 2017

Reference for this Article

2017 AF Symposium LIVE VIDEO: Can Adding Fibrosis Improve Ablation Success?

Updated March 9: We added two new slides comparing the patient’s initial and subsequent DE-MRI images.

Report 13 from 2107 AF Symposium: In a live ablation from from Mass. General Hospital in Boston, Drs. Heist and Van Houzen demonstrated a pioneering strategy to treat Atrial Fibrillation patients with patchy fibrotic areas of tissue. This tissue perpetuates A-Fib.

First, a DE-MRI scan defines and measures the heart’s areas of fibrosis. Next, the doctors ablated (or filled in) these patchy areas with more fibrosis (i.e., ablation scarring) turning the patchy areas into dense fibrotic areas. Transforming patchy fibrotic tissue to dense fibrotic tissue stops A-Fib signals from perpetuating in that tissue.

It may seem counter-intuitive―create more fibrosis to make patients A-Fib free. Read more about this innovative strategy.

2017 AF Symposium Live Video: Adding Fibrosis to Improve Ablation Success?

2017 AF Symposium

Live Case: Can Adding Fibrosis Improve Ablation Success?

Updated March 13: We added two new slides.

Streaming video of an ablation by Drs. Kevin Heist and Nathan Van Houzen from Massachusetts General Hospital (MGH) in Boston, MA (moderator, Dr. Moussa Mansour).

Patient background: The case of a 62-year-old male with symptomatic persistent A-Fib, despite a previous ablation 8/9/2016. Propafenone, amiodarone, and an electrical cardioversion weren’t effective. The patient had been taken off amiodarone a week before this ablation. They cardioverted him into sinus rhythm to better measure areas of low voltage (areas of fibrosis). Low voltage areas were defined as less than 0.5 V.

Mapping Views: Lesions and Remaining Fibrosis From First Ablation

THE TOP SLIDE: The RF point-by-point ablation lesions from the patient’s first ablation done months before the live case.

RED dots represent a greater force or more time making the lesion; PINK dots represent a lower efficiency lesion due to proximity to the esophagus.

Some of these PINK dot area had reconnected and had to be re-ablated during the live case.

(“PA” is  the left atrium viewed from the back.)

THE BOTTOM SLIDE: The MRI done shortly before the live case. The BLUE areas are normal atrial tissue. The RED areas are fibrotic/scarred areas. Some of the red areas in this PA view were not ablated during the first procedure and represent spontaneous fibrosis.

Live: Ablating Areas of Fibrosis

In this live procedure from Boston, MA, Drs. Heist and Van Houzen did a normal PVI and found evidence that some areas from the patient’s previous ablation had reconnected.

The innovative aspect of this ablation is they also ablated areas of fibrosis. ‘Spontaneous fibrosis’ tends to be patchy in a way that perpetuates A-Fib.

Ablating or filling in these patchy areas with more fibrosis (i.e., ablation scarring) turns the patchy areas into dense fibrotic areas which can’t conduct or perpetuate A-Fib.

They first performed a Delayed Enhancement MRI (DE-MRI) scan of this patient’s heart in order to define and measure the areas of fibrosis.

The EPs then ablated (filled in) areas of this fibrosis, turning these patchy fibrotic regions into denser fibrotic areas. These dense fibrotic areas no longer conducted or perpetuated A-Fib.

Two months after the ablation the patient is doing well in sinus rhythm. Whereas after his first ablation, he experienced early recurrence.

What Patients Need to Know

Who Benefits from this Strategy? Adding or filling in patchy fibrotic areas with more fibrosis through ablation is a very innovative ablation strategy.

It is being applied to patients with persistent or persistent long-standing A-Fib who usually have more fibrosis, but is also being applied to paroxysmal patients who have had a durable (successful) PVI but are still in A-Fib (they often have some fibrotic areas).

The term ‘spontaneous fibrosis’ refers to fibrosis (scarring) which occurs naturally, that is, without a doctor’s procedural intervention.

Impractical for Diffused Fibrosis: This strategy doesn’t work if someone has a generalized distribution of fibrous tissue throughout their atrium. It would require ablation of the whole atrium creating too much fibrosis and causing other heart function problems.

Isn’t Creating More Fibrosis Dangerous for Patients? It certainly does seem counterintuitive―create more fibrosis to make patients A-Fib free. But we are looking at patients who already have patches of fibrosis. (If we could turn these fibrotic areas back into smooth heart muscle, then this strategy wouldn’t be necessary.)

This strategy can make people with difficult A-Fib cases A-Fib free, and make a huge difference for patients who have failed ablations.

While this strategy is exciting, we are only at the very beginning stages of this research.

Acknowledgements:

Nassir Marrouche MD

N. Marrouche MD

Dr. Nassir Marrouche: The concept of ablating areas of fibrosis was conceived by Dr. Nassir Marrouche of the University of Utah (CARMA). Dr. Marrouche has started DECAAF II, a clinical study on fibrosis to compare ablation of fibrosis areas to standard PVI ablation.

Known for the completed DECAAF study, Dr. Mansour is now collaborating with Dr. Marrouche on the DECAAF II study, and Massachusetts General Hospital (the originating site of this live streaming video) is one of the participating sites. For more, see my 2017 AF Symposium article A-Fib Increases Fibrosis.

Dr. Kevin Heist: I would like to thank Dr. Kevin Heist, Mass. General Hospital, for patiently explaining to me the concept, rationale and strategy of ablating areas of fibrosis. (I really needed his help!)

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Reference for this Article

2017 AF Symposium: LIVE Video Ablation With Non-Contact Catheter Mapping

The Acutus Medical Non-Contact basket catheter with multiple electrodes

The Acutus Medical Non-Contact basket catheter with multiple electrodes

Report 12 from 2107 AF Symposium: In a live case from Prague, the Czech Republic, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used Acutus Medical’s basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. …Read my full report…

Atrial Fibrillation and Atrial Flutter: Cause and Effect?

About Atrial Fibrillation and Atrial Flutter…are they linked? Does one precede the other? Can one procedure fix both? Can a typical catheter ablation fix both Atrial Fibrillation and Atrial Flutter at the same time? Can Maze surgery or Mini-maze surgery fix both?

Surgery vs. Ablation

In general, Atrial Flutter originates in the right atrium and Atrial Fibrillation in the left atrium.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter. If you have both A-Fib and A-Flutter, a Maze procedure needs to be followed by a catheter ablation to fix the Atrial Flutter.

A catheter ablation procedure for A-Flutter is relatively easy and it’s highly successful (95%). It usually involves making a single line in the right atrium which blocks the A-Flutter (Caviotricuspid Isthmus line).

A Catheter Ablation Two-Fer? 

If you are having a catheter ablation, many doctors make this Caviotricuspid Isthmus ablation line while doing an A-Fib ablation (in the left atrium)—even if you don’t have A-Flutter at the time.

Catheter inserted into the heart and through septum wall into Left Atria

Catheter inserted into the heart and through septum wall into Left Atria

Catheters enter the heart through the right atrium. At the beginning of a catheter ablation for atrial fibrillation, doctors enter the heart through the right atrium. While there they may elect to make the right atrium ablation line at this point which takes 10-20 minutes.

They then go through the wall separating the right and left atria (transseptal wall) to do the ablation for A-Fib in the left atrium. (Some doctors chose to place the right atrium ablation line at the end of an ablation when they withdraw from the left atrium into the right atrium.)

Some say one should “do no harm” and not make this right atrium ablation line if there is no A-Flutter. Saying it can always be done later in another catheter ablation at little risk to the patient.

Research: Are A-Fib and A-Flutter Linked?

While you can have A-Flutter without A-Fib, more often than not, they are linked. When you have A-Flutter, A-Fib often lurks in the background or develops later.

Patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

Some A-Flutter may originate in the left atrium, or the A-Flutter may mask A-Fib which may appear later after a successful A-Flutter ablation.

As many as half of all patients ablated for A-Flutter may later develop A-Fib.

In a small research study, patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

What Patients Need to Know

But right now we can’t say for sure if one causes the other. We do know that A-Flutter usually comes from the right atrium, while A-Fib usually comes from the left atrium.

Resources for this article

Live Case: Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

2017 AF Symposium

Live Case: Ablation Using Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

Illlustration: Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Video streaming of an ablation from Na Homolce Hospital in Prague, the Czech Republic with Drs. Peter Neuzil, Jan Petru, and Jan Skoda.

The doctors used a new high resolution mapping system from Acutus Medical to identify in real time where his A-Fib signals were coming from.

Patient background: A 68-year-old man in paroxysmal A-Fib had a CHA2DS2-VASc score of 4 with hypertension and a pulmonary embolism. He had had a PVI in January 2011 and a repeat PVI to fix gaps in April 2011. His A-Fib recurred in 2014. Electrical cardioversions didn’t work.

Non-Contact Mapping with Ultrasound-Electrode Catheter

VIDEO: For a more detailed explanation of the Non-Contact Dipole Density AcQ Imaging and Mapping, see the video from Acutus Medical.(1:54)

The Acutus Medical Non-Contact Dipole Density AcQ Imaging and Mapping catheter uses a basket catheter with multiple electrodes and ultrasound anatomy reconstruction.

‘Non-contact’ means the basket catheter can float freely in the left atrium and doesn’t have to be applied to the surface of the heart to generate A-Fib maps.

The basket catheter has six splines each with eight nodules that contain 48 ultrasound transducers and 48 electrodes. The ultrasound pings the atrium wall and rapidly produces a 3D left atrium anatomy.

Electrical Measurement: Dipole Density vs Voltage

For over one hundred years, voltage has been the major electrical measurement in cardiac medicine. The limitation with using voltage in electrophysiology is that the reading includes both the localized charge (Dipole Density) as well as the sum of the surrounding sources providing a broad, blended view of cardiac activity.

According to Acutus Medical, by eliminating these surrounding sources, and using dipole density (instead of voltage) the field of view becomes sharper and narrower.

This more precise electrical activation is displayed as a Dipole Density map on a 3D ultrasound reconstruction of the heart.

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Live Streaming Video: Ablation from Prague

In the live case, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used the basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. When they made a mitral isthmus line, the patient’s A-Fib terminated which restored him to normal sinus rhythm.

What Patients Need To Know

May Replace Contact Mapping: Non-contact mapping is a significant innovation in catheter ablation and may eventually replace existing contact mapping catheters and make ablations easier. It also seems to require less technical skill than in a traditional contact mapping system.

“Non-contact mapping is a significant innovation and may eventually replace existing contact mapping catheters.”—Steve Ryan

No Radiation & Instantaneous: Using ultrasound to produce a 3D rendering of the heart is innovative and could change the way the anatomy of the heart is generated for an ablation. And unlike a CT scan, it doesn’t use radiation. Also, unlike a CT scan, the ultrasound images of the heart are generated instantaneously in real-time.

Higher Resolution: Dipole Density mapping may prove to be a higher resolution system than current mapping systems.

Not Yet Available in U.S.: But don’t expect the Acutus Medical System to become available in the U.S. any time soon. It isn’t yet FDA approved or available for sale in the U.S.

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Reference for this Article

2017 AF Symposium: Three New Reports—Genetic A-Fib and LIVE Streaming Video Ablations

Live Streaming Video from AF Symposium at A-Fib.com

To my 2017 AF Symposium Overview, I added how we observed in-progress A-Fib procedures via streaming video from five locations spanning the globe, and heard from the EPs performing the ablations. Continue to the Video Overview…

Report 11: LIVE! Ablation Using CardioFocus Laser Balloon

CardioFocus HeartLight Laser Balloon catheter

CardioFocus HeartLight Laser Balloon catheter

Video streaming from Na Homolce Hospital in Prague, The Czech Republic. Drs. Peter Neuzil, Jan Petru and Jan Skoda did an ablation using the CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon (FDA approved April 4, 2016).

The doctors showed how they could directly see the Pulmonary Vein opening they were ablating (unlike RF and CryoBalloon systems). The center of the catheter has an endoscopic (looking inside) camera.

(To me, this is a major advantage and ground-breaking improvement for patients.)

Read more of my report, and see a short video clip with an actual view of the pulmonary veins during an ablation. …Continue reading my report….

Report 10: LIVE! Two Procedures—but Different Left Atrial Appendage Occlusion Devices

Featuring the Amplatz Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.

Amplatz Amulet occlusion device by St. Jude Medical - A-Fib.com

Amplatz Amulet occlusion device by St. Jude Medical

Live from Milan, we watched the doctors insert an Amplatz Amulet into the LAA of a 78-year-old women who had a high risk of bleeding.

These doctors did something I had never seen before. They made a physical model of the woman’s LAA, then showed how the Amplatz Amulet fit into the model. This helped AF Symposium attendees see how the Amplatz Amulet actually worked. …Continue reading my report…

Report 9: World-Wide Studies on Genetic A-Fib

DNA: Double helix graphic at A-Fib.com

Dr. Patrick Ellinor of Mass. General Hospital, Boston MA, reported the biggest news is that A-Fib genetic research is increasing exponentially. The AFGen Consortium website lists 37 different studies and world-wide institutions studying A-Fib genetics with over 70,000 cases. Within the next 10 years, Dr. Ellinor and his colleagues hope to identify over 100 different genetic loci for A-Fib.

Dr. Ellinor reported that using a genetic “fingerprint” of A-Fib helps to identify those patients at the greatest risk of a stroke. (There’s a 40% increased risk of developing A-Fib if a relative has it.)…Continue reading my report…

About the Annual AF Symposium

The annual AF Symposium brings together the world’s leading medical scientists, researchers and EPs to share recent advances in the treatment of atrial fibrillation. You can read all my summary reports on my 2017 AF Symposium page.

Video: A Live Case of Catheter Ablation for Long-Standing Persistent A-Fib Through 3D Mapping & ECG Images

Presented entirely through 3D mapping and ECG images, a live demo of ablation for long-standing, persistent A-Fib is followed from start to finish. Titles identify each step. No narration, music track only (I turned down the volume as the music track was distracting.)

3D mapping and ECG images show the technique of transseptal access, 3D mapping, PV isolation, and ablating additional drivers of AF in the posterior wall and left atrial appendage. (8:03) Produced by Dr. James Ong, Heart Rhythm Specialist of Southern California.

NOTE: Before viewing this video, you should already have some basic understanding of cardiac anatomy and A-Fib physiology.


YouTube video playback controls:
 
When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

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Video: When Drug Therapy Fails: Why Patients Consider Catheter Ablation

For Insidermedicine.com. Dr. Susan M. Sharma discusses why patients with atrial fibrillation turn to ablation when drug therapy doesn’t work. Presenting research findings by David J. Wilber and MD; Carlo Pappone, MD, Dr. Sharma discusses the success rates of drug therapy versus catheter ablation. (See transcript below.) (3:00 min.) Published Jan. 26, 2010 on Insidermedicine.com.

 

Transcript of this video
Research Reference for this Video

If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017

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VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected

Dr. Patrick Tchou and Dr. Bryan Baranowski, cardiologists from the Cleveland Clinic describe the catheter ablation procedure for the treatment of atrial fibrillation (A-Fib), what it is, how it’s done and what results can be expected from this surgery.

Excellent animations: showing A-Fib’s chaotic signals, and the pattern of ablation scars around the openings to the pulmonary veins. By the Cleveland Clinic (4:00 min.)

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select. 

If you find any errors on this page, email us. Y Last updated: Saturday, May 27, 2017

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Video: Inside the EP Lab with Dr. James Ong: Using Mapping & CT Scan Technologies During a Pulmonary Vein Isolation

Cardiac Electrophysiologist Dr. James Ong begins with a brief tour of the EP lab and control room; Dr. Ong explains how pulmonary vein isolation is done with radiofrequency ablation to cure atrial fibrillation.

Included are: Mapping technology; the Virtual Geometrical shell of the heart displayed next to the CT scan; Placement of the catheter, real time tracking; the Complex Fractionated Electrogram (CFE) Map used to identify and eliminate the extra drivers (aside from the pulmonary veins). (6:01) From a series of videos by Dr. Ong, Heart Rhythm Specialists of Southern California.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.


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email us. Y Last updated: Saturday, February 18, 2017

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2017 AF Symposium Video Streaming: Ablation using CardioFocus Laser Balloon

2017 AF Symposium

Live Case: Ablation using CardioFocus Laser Balloon

Video clip: :16 sec view of pulmonary view opening during ablation with HeartLight System; from ‘Ablate What You See & See What You Ablate’.

Video streaming from Na Homolce Hospital in Prague, The Czech Republic. Drs. Peter Neuzil, Jan Petru and Jan Skoda, in their second live case, did an ablation using the CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon (FDA approved April 4, 2016).

Direct Visualization

The doctors showed how they could directly see the Pulmonary Vein opening they were ablating (unlike RF and CryoBalloon systems).

The center of the catheter has an endoscopic (looking inside) camera. (To me, this is a major advantage and ground-breaking improvement for patients.) (Watch :13 video clip)

Laser Energy For Ablation

CardioFocus HeartLight Laser Balloon at A-Fib.com

CardioFocus HeartLight Laser Balloon

In the center of the catheter is an optical fiber which produces an arc of laser (near infrared) energy. When they applied this laser energy, it looked like a green flashing light that circled the PV.

The doctors said that watching this circulating green arc allowed them to visually see if they were making complete circular lesions of the PV.

They later used a regular Lasso catheter to check for ablation integrity.

Variable Diameter Compliant Balloon

The doctors also showed how the CardioFocus HeartLight system uses a variable diameter compliant balloon which can be sized to fit into a wide range of PV openings.

See our library of videos about Atrial Fibrillation

One preliminary research article suggested that the Laser Balloon system clinical outcomes were an improvement over CryoBalloon ablation. 

VIDEO ANIMATION: For a one-minute animation of how the CardioFocus HeartLight system works, see Visually Guided Ablation.

Editor’s Comments:
The CardioFocus HeartLight Laser Balloon catheter seems like a major advance in the treatment of A-Fib, To be able to look directly at the PV opening instead of using fluoroscopy, etc. should make an EP’s ablation task much easier and potentially more effective. And having a variable diameter compliant balloon is an added plus.
But when I talked with the CardioFocus rep at the AF Symposium exhibit hall, he said they were in the process of rolling out the Laser Balloon system to various centers. It may be a short while till the system is up and operational nationwide in the U.S. (It’s already in use in Europe.) We will try to list which centers use the Laser Balloon system.
If real world experience proves its effectiveness, the CardioFocus HeartLight Laser Balloon system may eventually make CryoBalloon ablation a secondary player.

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Resources for this article

FAQs A-Fib Treatments: Catheter Ablation Procedures

Catheter ablation illustration at A-Fib.com

Catheter ablation

Atrial Fibrillation patients seeking a cure and relief from their symptoms often have many questions about catheter ablation procedures. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer)

1. Heart Function: “Does this burning and scarring during the ablation procedure affect how the heart functions? Should athletes, for example, be concerned that their heart won’t function as well after an ablation?”

Related question: “I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.”

2. Radiation: “How dangerous is the fluoroscopy radiation during an ablation? I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib—A-Fib destroys my life. I’m worried about radiation exposure.”

3. Condition of Heart: “What is an enlarged heart? Does it cause A-Fib? I was told I can’t have a catheter ablation because I have an enlarged heart. Why is that?”

Related question: I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?”

Related question:  I have a defective Mitral Valve. Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?”

4. Age: “I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?”

Related question:I’m 80 and have been in Chronic (persistent/permanent) A-Fib for 3 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation?

5. Blanking Period: “How long before you know a Pulmonary Vein Ablation procedure is a success? I just had a PVA(I). I’ve got bruising on my leg, my chest hurts, and I have a fever at night. I still don’t feel quite right. Is this normal?”

Related question: Since my ablation, my A-Fib feels worse and is more frequent than before, though I do seem to be improving each week. My doctor said I shouldn’t worry, that this is normal. Is my ablation a failure?”

6. O.R. Report: I want to read exactly what was done during my Pulmonary Vein Ablation. Where can I get the specifics? What records are kept?”

7. Procedure Length: “What is the typical length of a catheter ablation today versus when you had your catheter ablation in 1998 in Bordeaux, France? What makes it possible?”

8. Clots/Blood Thinners: “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin, an NOAC or aspirin?”

Related question:I was told that I will have to take an anticoagulant for about 2-3 months after my ablation. Afterwards shouldn’t there be even less need for a prescription anticoagulant rather than more?”

Related question: During an ablation, how much danger is there of developing a clot? What are the odds? How can these clots be prevented?”

9. Exercise: “I’m having a PVA and I love to exercise. Everything I read says ‘You can resume normal activity in a few days.’ Can I return to what’s ‘normal’ exercise for me?”

10. Non-PV Triggers: “Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots? I had a successful catheter ablation and feel great. Could they eventually be turned on and put me back into A-Fib?

11. Heart Rate: “I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

12. The Bordeaux Group: “I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?”

13. Cure? “I have Chronic Atrial Fibrillation. Am I a candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?”

Related question: I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a ‘cure’. If I take meds like flecainide which stop all A-Fib symptoms and have no significant side effects, isn’t that a ‘cure?’”

14. Tech Advances: “I’m getting by with my Atrial Fibrillation. With the recent improvements in Pulmonary Vein ablation techniques, should I wait until a better technique is developed?”

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FAQs: Does Ablation Treat Symptoms or “Cure” Atrial Fibrillation?

Catheter Ablation

FAQs A-Fib Ablations: Is it a Cure?

“I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a “cure.” If I take meds like flecainide which stop all A-Fib symptoms and have no significant side effects, isn’t that a ‘cure?’”

A successful catheter ablation doesn’t just treat A-Fib symptoms, it physically changes your heart.

Isolates PVs: An ablation closes off the openings around your pulmonary veins (PVs) so A-Fib signals from the Pulmonary Veins (PVs) can no longer get into your heart. It electrically ‘isolates’ your PVs. If successful and permanent, you should be protected from developing A-Fib that originates from your PVs (where most A-Fib originates).

Recurrence Rates: Older research showed that recurrence of A-Fib after an ablation occurred at a 7% rate out to five years. But this was before the use of the newer techniques of Contact Force Sensing catheters and CryoBalloon ablation which make more permanent lesion lines around your Pulmonary Veins.

Also, people with comorbidities, like sleep apnea, obesity, diabetes, hypertension, tend to have more recurrences. Sleep apnea can cause A-Fib to develop in other parts of the heart besides the Pulmonary Veins.

Worst case scenario: But let’s discuss a worst case scenario after a successful catheter ablation. Let’s say that five years later, your A-Fib reoccurs. Usually, all that’s necessary is for a touch-up ablation to fix some gaps in the isolation burns around the openings to the PVs or other spots. It’s usually a much easier, faster procedure than your original ablation. Often, that’s all that’s necessary to keep you A-Fib free.

No Magic Pill for A-Fib: In more than 40% of cases, antiarrhythmic drugs don’t work, cause bad side effects, or lose their effectiveness over time. We don’t currently have a magic pill you can take which will guarantee to forever cure you of A-Fib.

I’m glad that flecainide works for you, but it’s not generally considered a permanent cure for A-Fib.

Catheter Ablation Only Hope of a “Cure”: The bottom line is that catheter ablation (and some surgeries) currently offers the only hope of a permanent cure of A-Fib. That doesn’t mean that all A-Fib ablations are 100% successful. Catheter ablation is a relatively new field where there is still a lot to learn. But catheter ablation is a low-risk procedure with a high rate of success. Right now, it’s the best that medical science has to offer to fix Atrial Fibrillation.

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Finally in Sinus Rhythm After 4 Years in Chronic Asymptomatic Atrial Fibrillation

Roger Finnern, personal A-Fib story at A-Fib.com

Roger Finnern

A-Fib Patient Story #94

Finally in Sinus Rhythm After 4 Years in Chronic Asymptomatic Atrial Fibrillation

By Roger Finnern, Tempe, AZ, February 2017

Steve, I had to let you know how thankful I am for all your recommendations and help over the past year. Feel free to use the following on your website or whatever, to give hope to others going through the process.

My Atrial Fibrillation: I was Told to “Just Live with It.”

I contacted you last in December 2015 as I was in chronic A-Fib without symptoms, age 67, and  I had a cardiologist who wanted me to do nothing but take a low dose aspirin and live with it.

My cardiologist wanted me to do nothing [about my A-Fib] but take a low dose aspirin and live with it.

After two years of being in Chronic A-Fib, I went out on my own. With your recommendation, I contacted Dr. Vijay Swarup, Arizona Heart Rhythm Center. I ended up getting a RF ablation in early February 2016.

After Ablation, Back in A-Fib

After my ablation, I was in rhythm only 2 days before it reverted. They performed cardioversion twice before releasing me from the hospital, and each worked only for a minute before reverting back.

Dr. Swarup was a bit miffed as he had tested all ablated points and could not produce any response back to A-fib. He said something to the effect that my heart was highly irritated. They put me on the antiarrhythmic drug amiodarone to convert at home.

Amiodarone Works—Finally in Sinus After 4 Years!

The amiodarone worked, and one week later I saw my doctor and had my first normal EKG since 2013!

One week later I saw my doctor and had my first normal EKG since 2013!

On August 2, six months post-ablation, I was taken off amiodarone. (I was kept on amiodarone longer than normal, due to the rough time we had getting into rhythm initially.)

Being on amiodarone over a long period, I was fortunate that I seemed to not have bad side effects. But I did notice after being off it for a while, that I breathed easier.

Need a Blood Thinner If In Normal Sinus Rhythm?

I was maintaining normal rhythm, so during my October 25, 2016 appointment, I asked Dr. Swarup about getting off the blood thinner Eliquis. .

..he ordered a TEE to check the strength, shape, etc. of my left atrial appendage.

So he ordered a Transesophageal Echocardiogram (TEE) to check the strength, shape, etc. of my left atrial appendage (LAA). From that we could also determine if Eliquis or the Watchman occlusion device would otherwise be feasible. [If blood isn’t being pumped out properly from the LAA, there is more risk of clots forming and stroke, even if one is in sinus rhythm.]

My LAA pumping velocity was good. Dr. Swarup has taken me off Eliquis, so things have turned out exceptionally well for me.

I had been taking 1 gram of krill oil with the Eliquis. Now that I am off Eliquis, I have decided to double it for now just in case―strictly a personal choice.

Sleep Apnea Study―Philips DreamWear Mask

During the last nine months [post-ablation] I wore a heart monitor [e.g. halter or event monitor] for a 10 day period.

I also did a sleep study at home―required by Dr. Swarup. They furnish the equipment, and it is fairly easy to do. I turned out to have mild sleep apnea.

I did a sleep study at home and I turned out to have mild sleep apnea.

I have been on a CPAP [Continuous positive airway pressure] machine for the past two months. My episode numbers reduced considerably, so they are happy with the results.

Probably like everyone else, I did not think I could handle the mask, but it has turned out just fine. I highly recommend the DreamWear mask by Philips as it is very comfortable, only one strap, and a pillow type cushion under the nose. I barely know I am wearing a mask.

I have also travelled through airports with the machine in a provided carry-on case and have had no problems whatsoever. It also does not count toward your carry on limit as it is a medical device.

Acupuncture Helps

Throughout my process, I went to a highly experienced acupuncturist about once every week and I will probably continue to do this forever.

This opened up the field of eastern medicine to me, which I now have a healthy respect for.

Steve, she was well aware of the heart points you had in an article on the website way back and had a few others of her own. [See my article: Acupuncture Helps A-Fib: Specific Acupuncture Sites Identified.)

While those points were used by doctors to maintain rhythm after an ablation, I tried them before the ablation just to see if they might work anyway. This opened up the field of eastern medicine to me, which I now have a healthy respect for. I think there is definitely something to this, as it seems to have such a calming effect.

I Feel Fantastic!―But I know This is a Process

Who knows what the future brings, but I feel fantastic and wanted to let you know, Steve, how grateful I am to you for your guidance.

Dr. Swarup says this is a process…we got the rhythm back and now the job is to keep it.

Lessons Learned

Recognize that Tiredness May Be a Symptom of A-Fib: My A-Fib first showed up on a routine physical. Looking back, other than some tiredness, I hadn’t noticed any thing unusual up to that point. Since I stay in good shape, hiking, biking, golf, and some high intensity interval exercises, I had just attributed the tiredness to getting older and just kept on going.

I Waited Longer Than I Should Have: The EKG in April, 2014 which showed that I had A-Fib really shocked me. I did my research, found your website [A-Fib.com], and learned all about magnesium and acupuncture.

In hindsight, I waited longer than I should have. But I had to find out if these natural treatments would straighten out my A-Fib condition without going through an ablation procedure.

Doubted my Cardiologist’s Advice: Also, a cardiologist told me to do nothing since I had no symptoms, though in my mind I started doubting him almost from the beginning.

Get an Ablation Sooner Rather Than Later…But May Not be Easy: My lesson learned is to plan for an ablation sooner than later.

My experience with the ablation and the required cardioversions in a three-day period in the hospital really knocked me for a loop.

And don’t think that this will necessarily be an easy procedure. Everyone is different. My experience with the ablation and the required cardioversions in a three-day period in the hospital really knocked me for a loop. Despite my relatively good physical condition, I definitely had a case of the rubber legs.

I personally recommend to anyone getting an ablation, that you should plan on taking a week or even two off work to really recover before getting back to your normal routine.

Need for Second Ablation? If I ever have to do a second ablation, I will probably go ahead. But I will have to think long and hard about what kind of symptoms I have, as well as how much older I am.

The future is just speculation. As for now, having an ablation was definitely the right decision and turned out great.

Thanks again,
Roger Finnern, Tempe, AZ

Editor’s Comments:

Amiodarone Dangerous Drug: Amiodarone is the strongest and often the most effective antiarrhythmic drug, but it’s also the most toxic. (See my post Amiodarone Effective But Toxic)
Amiodarone is used in difficult cases like Roger’s after his ablation to get his heart in the habit of beating normally, but usually only for a short period of time.
It has to be carefully monitored for bad side effects. Some say amiodarone is so toxic that it shouldn’t be used at all, even in cases like Roger’s. It’s a difficult decision. It worked for Roger, but he did notice that amiodarone affected his lungs and breathing. “After being off of it…I breathed easier.”
“No Symptom” A-Fib May Not be Accurate: Some say that there really is no such thing as Asymptomatic A-Fib, that people just get used to how A-Fib affects them and put up with it. That seems to have been the case with Roger. He writes that now being in normal sinus rhythm feels “fantastic!” and very different than being in Chronic “asymptomatic” A-Fib.
Some would say that because Roger had few noticeable symptoms and was in Chronic A-Fib for some time, that it wasn’t justified to perform a catheter ablation on him. But A-Fib is a progressive disease. See my Editorial: Leaving the Patient in A-Fib—No! No! No! for a list of damage caused by A-Fib over time.
For Roger, being A-Fib free has radically improved his health and quality of life. Even if you are “asymptomatic,” you may still want to be A-Fib free. You have a right to do so.
Blood Thinners after an Ablation? Some would say that Roger should forever be on blood thinners (especially drug companies) for continued risk of stroke, even if he is A-Fib free.
But research indicates that a successful ablation reduces the risk of stroke to that of a normal person. (See my FAQs A-Fib Ablations: Blood Thinner Post-Ablation?) Blood thinners are not like taking vitamins. They have their own risks, like causing bleeding.
A Very Difficult Case: Someone in Chronic A-Fib for a long time is usually the hardest to ablate and make A-Fib free. In addition to the Pulmonary Veins (PVs), their hearts often have many non-PV triggers which have to be carefully mapped and ablated.
Not all EPs have this level of skill and experience. Roger was fortunate to go to Dr. Vijay Swarup who seems to have made Roger A-Fib-free after only one ablation.
O.R. Operating Room Report: Roger’s OR report showed how Dr. Swarup had to work very hard to find and ablate all of Roger’s non-PV triggers. After isolating Roger’s PVs, Roger was still in atypical atrial flutter, often one of the hardest arrhythmias to find and ablate. Dr. Swarup had to make a Mitral Isthmus ablation line and a Left Atrium roof line.
Then Dr. Swarup found right atrium flutter and made a caviotricuspid isthmus line to block it.
Afterwards, when Dr. Swarup administered isoproterenol to Roger to stimulate any remaining non-PV triggers, he found a tachycardia coming from an unusual spot―the posterior-septal aspect of the tricuspid annulus. (In all the O.R. reports I’ve read, I’ve never heard of an A-Fib signal coming from this spot.) When Dr. Swarup ablated this focal site, Roger terminated into sinus rhythm. That’s the best result an EP can hope for from an ablation. Further administering of Isoproterenol couldn’t produce any other non-PV trigger sites in Roger.
If his A-Fib Returns: Roger knows that he may not be completely out of the woods yet. A second ablation will usually take care of any gaps or hidden triggers and will often be a much easier, faster ablation than the first.
And each day Roger is in normal sinus rhythm and A-Fib free makes his heart healthier, stronger and more apt to beat normally. Not to mention how much better Roger feels both physically and emotionally.

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If you find any errors on this page, email us. Y Last updated: Sunday, March 26, 2017

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FDA Approved: CardioInsight (ECGI) Mapping and Ablation System Now Available in U.S.

CardioInsight 3D system vest - A-Fib.com

CardioInsight 3D system vest

Medtronic’s CardioInsight Noninvasive 3D Mapping System (ECGI) has received FDA clearance for use in the U.S. The CardioInsight system is the first non-invasive mapping system in the world.

Dr. Vivek Reddy at Mount Sinai Medical Center in New York City was the first to use the system commercially in the U.S.

CardioInsight Noninvasive 3D Mapping System (ECGI)

The CardioInsight system allows physicians to locate the origin of a patient’s irregular heart rhythms (arrhythmias). Cardiac mapping is traditionally achieved by inserting a catheter into the heart via an artery or vein.

The CardioInsight 3D system instead uses a 252-electrode sensor vest to non-invasively (from outside the heart) map irregular rhythms like A-Fib. The vest is a single-use, disposable multi-electrode vest that gathers cardiac electrophysiological data from the body surface. The 3D mapping system combines these signals with CT scan data to produce and display simultaneous 3-D cardiac maps.

The vest technology contours to the patient’s body and allows for continuous and simultaneous panoramic mapping of both atria or both ventricles, which cannot be achieved with current invasive methods. The 3D cardiac maps can be created by capturing a single heartbeat, and enable rapid mapping of these heart rhythms.

VIDEO: To learn how the vest is applied to the patient, see the vest application instructional video at the Medtronic CardioInsight™ Mapping Vest webpage.

ECGI is a Major Breakthrough in Treating A-Fib

ECGI mapping is certainly one of, or even the most important new development in the treatment of A-Fib.

In 2013, I started reporting about this ECGI system. Prof. Haissaguerre and his colleagues in Bordeaux, France, were very active and instrumental in the use of the CardioInsight system. They are credited with the greatest number of presentations and publications on the system. CardioInsight expanded its rollout to eight different venues in Europe where it tested as well as it did at Bordeaux. It’s now available in the U.S.―great news for patients.

Back then, I predicted that “the ECGI system, barring unforeseen circumstances, would rapidly supersede all other mapping systems and will become the standard of care in the treatment of A-Fib patients.”

David Neth wearing ECGI vest before ablation by the Bordeaux Groups - A-Fib.com

David Neth wearing ECGI vest before ablation by the Bordeaux Group

Not only does the CardioInsight (ECGI) system produce a complete, precise, 3D, color video of each spot in a patient’s heart producing A-Fib signals, but also the video can be done by a technician before the procedure right at the patient’s bedside rather than by the  electrophysiologist (EP) during an ablation. It also can be used during the procedure, for example to re-map an ablated area.

Dr Vivek Reddy stated: This system shifts mapping away from the EP lab, potentially saving time and enhancing the patient experience.”

The CardioInsight map is a better, more accurate, more complete map than an EP can produce by using a conventional mapping catheter inside the heart.

Should You Wait on Your Ablation for ECGI Mapping?

From a patient’s perspective, CardioInsight (ECGI) reduces both the time it takes to do an ablation and the number of burns a patient receives.

The question for patients is, should you wait on having an ablation till a CardioInsight  mapping system is available at your center?

The CardioInsight mapping system is most effective in cases of persistent or long-standing persistent A-Fib.

The CardioInsight mapping system is most effective in cases of persistent or long-standing persistent A-Fib where non-PV triggers have developed. Most cases of short-duration, paroxysmal A-Fib haven’t usually developed a lot of non-PV triggers.

Hence, if you’ve only been in A-Fib for a relatively short time and are still paroxysmal, it’s probably not worth the wait.

Medtronic Rollout of CardioInsight System

Medtronic will employ a strategic rollout of the technology in the geographies where it is cleared. I will try to report when an A-Fib center in the U.S. receives a CardioInsight system..

To read more about the CardioInsight (ECGI) system, see my article, How ECGI (Non-Invasive Electrocardiographic Imaging) Works.

Disclosure: Dr Vivek Reddy consults for and receives research funding from Medtronic.

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